INSTRUCTIONS: This survey asks for your view about your hip. This information will help us keep track of how you feel about your hip and how well you are able to do your usual activities.

Answer every question by ticking the appropriate box. If you are unsure about how to answer a question, please give the best answer you can.

Symptoms - These questions should be answered thinking of your hip symptoms during the last week.

S1. Do you feel grinding, hear clicking or any other type of noise from you hip?

Never

Rarely

Sometimes

Often

Always

S2. Difficulties spreading legs wide apart

None

Mild

Moderate

Severe

Extreme

S3. Difficulties to stride out when walking

None

Mild

Moderate

Severe

Extreme

Stiffness - The following questions concern the amount of joint stiffness you have experienced during the last week in your hip. Stiffness is a sensation of restriction or slowness in the ease with which you move your hip joint.

S4. How severe is your hip joint stiffness after first wakening in the morning?

None

Mild

Moderate

Severe

Extreme

S5. How severe is your hip stiffness after sitting, lying or resting later in the day?

None

Mild

Moderate

Severe

Extreme

Subtotal:

Pain

P1. How often is your hip painful?

Never

Monthly

Weekly

Daily

Always

What amount of hip pain have you experienced the last week during the following activities?

P2. Straightening your hip fully

None

Mild

Moderate

Severe

Extreme

P3. Bending your hip fully

None

Mild

Moderate

Severe

Extreme

P4. Walking on flat surface

None

Mild

Moderate

Severe

Extreme

P5. Going up or down stairs

None

Mild

Moderate

Severe

Extreme

P6. At night while in bed

None

Mild

Moderate

Severe

Extreme

P7. Sitting or lying

None

Mild

Moderate

Severe

Extreme

P8. Standing upright

None

Mild

Moderate

Severe

Extreme

P9. Walking on a hard surface (asphalt, concrete, etc)

None

Mild

Moderate

Severe

Extreme

P10. Walking on an uneven surface

None

Mild

Moderate

Severe

Extreme

Subtotal:

Function, daily living - The following questions concern your physical function. By this we mean your ability to move around and to look after yourself. For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your hip.

Function, sports and recreational activities - The following questions concern your physical function when being active on a higher level. The questions should be answered thinking of what degree of difficulty you have experienced during the last week due to your hip.

SP1. Squatting

None

Mild

Moderate

Severe

Extreme

SP2. Running

None

Mild

Moderate

Severe

Extreme

SP3. Twisting/pivoting on your injured knee

None

Mild

Moderate

Severe

Extreme

SP4. Walking on uneven surface

None

Mild

Moderate

Severe

Extreme

Subtotal:

Quality of Life

Q1. How often are you aware of your hip problem?

Never

Monthly

Weekly

Daily

Constantly

Q2. Have you modified your life style to avoid potentially damaging activities to your hip?

Not at all

Mildly

Moderately

Severely

Totally

Q3. How much are you troubled with lack of confidence in your hip?

Not at all

Mildly

Moderately

Severely

Extremely

Q4. In general, how much difficulty do you have with your hip?

None

Mild

Moderate

Severe

Extreme

Subtotal:

Thank you very much for completing all the questions in this questionnaire.

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